A decade's experience with quality improvement in cardiac surgery using the Veterans Affairs and Society of Thoracic Surgeons national databases

Data-driven coaching to improve statewide outcomes in CABG: before and after interventional study

BACKGROUND

The impact of quality improvement initiatives program (QIP) on coronary artery bypass grafting surgery (CABG) remains scarce, despite improved outcomes in other surgical areas. This study aims to evaluate the impact of a package of QIP on mortality rates among patients undergoing CABG.

MATERIALS AND METHODS

This prospective cohort study utilized data from the multicenter database Registro Paulista de Cirurgia Cardiovascular II (REPLICCAR II), spanning from July 2017 to June 2019. Data from 4018 isolated CABG adult patients were collected and analyzed in three phases: before-implementation, implementation, and after-implementation of the intervention (which comprised QIP training for the hospital team). Propensity Score Matching was used to balance the groups of 2170 patients each for a comparative analysis of the following outcomes: reoperation, deep sternal wound infection/mediastinitis ≤30 days, cerebrovascular accident, acute kidney injury, ventilation time >24 h, length of stay <6 days, length of stay >14 days, morbidity and mortality, and operative mortality. A multiple regression model was constructed to predict mortality outcomes.

RESULTS

Following implementation, there was a significant reduction of operative mortality (61.7%, P =0.046), as well as deep sternal wound infection/mediastinitis ( P <0.001), sepsis ( P =0.002), ventilation time in hours ( P <0.001), prolonged ventilation time ( P =0.009), postoperative peak blood glucose ( P <0.001), total length of hospital stay ( P <0.001). Additionally, there was a greater use of arterial grafts, including internal thoracic ( P <0.001) and radial ( P =0.038), along with a higher rate of skeletonized dissection of the internal thoracic artery.

CONCLUSIONS

QIP was associated with a 61.7% reduction in operative mortality following CABG. Although not all complications exhibited a decline, the reduction in mortality suggests a possible decrease in failure to rescue during the after-implementation period.

Extracorporeal membrane oxygenation for cardiogenic shock: a meta-analysis of mortality and complications

BACKGROUND

Venoarterial extracorporeal membrane oxygenation (va-ECMO) is an advanced life support for critically ill patients with refractory cardiogenic shock. This temporary support bridges time for recovery, permanent assist, or transplantation in patients with high risk of mortality. However, the benefit of this modality is still subject of discussion and despite the continuous development of critical care medicine, severe cardiogenic shock remains associated with high mortality. Therefore, this work aims to analyze the current literature regarding in-hospital mortality and complication rates of va-ECMO in patients with cardiogenic shock.

METHODS

We conducted a systematic review and meta-analysis of the most recent literature to analyze the outcomes of va-ECMO support. Using the PRISMA guidelines, Medline (PubMed) and Scopus (Elsevier) databases were systematically searched up to May 2022. Meta-analytic pooled estimation of publications variables was performed using a weighted random effects model for study size.

RESULTS

Thirty-two studies comprising 12756 patients were included in the final analysis. Between 1994 and 2019, 62% (pooled estimate, 8493/12756) of patients died in the hospital. More than one-third of patients died during ECMO support. The most frequent complications were renal failure (51%, 693/1351) with the need for renal replacement therapy (44%, 4879/11186) and bleeding (49%, 1971/4523), bearing the potential for permanent injury or death. Univariate meta-regression analyses identified age over 60 years, shorter ECMO duration and presence of infection as variables associated with in-hospital mortality, while the studies reporting a higher incidence of cannulation site bleeding were unexpectedly associated with a reduced in-hospital mortality.

CONCLUSIONS

Extracorporeal membrane oxygenation is an invasive life support with a high risk of complications. We identified a pooled in-hospital mortality of 62% with patient age, infection and ECMO support duration being associated with a higher mortality. Protocols and techniques must be developed to reduce the rate of adverse events. Finally, randomized trials are necessary to demonstrate the effectiveness of va-ECMO in cardiogenic shock.

Quality improvement program at Latin America

BACKGROUND

The current challenge of cardiac surgery (CS) is to improve outcomes in adverse scenarios. The aim of this study was to assess the impact of a quality improvement program (QIP) on hospital mortality in the largest CS center in Latin America.

METHODS

Patients were divided into two groups: before (Jan 2013-Dec 2015, n = 3534) and after establishment of the QIP (Jan 2017-Dec 2019, n = 3544). The QIP consisted of the implementation of 10 central initiatives during 2016. The procedures evaluated were isolated coronary artery bypass grafting surgery (CABG), mitral valve surgery, aortic valve surgery, combined mitral and aortic valve surgery, and CABG associated with heart valve surgery. Propensity Score Matching (PSM) was used to adjust for inequality in patients' preoperative characteristics before and after the implementation of QIP. A multivariate logistic regression model was built to predict hospital mortality and validated using discrimination and calibration metrics.

RESULTS

The PMS paired two groups using 5 variables, obtaining 858 patients operated before (non-QIP) and 858 patients operated after the implementation of the QIP. When comparing the QIP versus Non-QIP group, there was a shorter length of stay in all phases of hospitalization. In addition, the patients evolved with less anemia (P = 0.001), use of intra-aortic balloon pump (P = 0.003), atrial fibrillation (P = 0.001), acute kidney injury (P < 0.001), cardiogenic shock (P = 0.011), sepsis (P = 0.046), and hospital mortality (P = 0.001). In the multiple model, among the predictors of hospital mortality, the lack of QIP increased the chances of mortality by 2.09 times.

CONCLUSION

The implementation of a first CS QIP in Latin America was associated with a reduction in length of hospital stay, complications and mortality after the cardiac surgeries analyzed.

Off pump coronary artery bypass in patients with an ejection fraction of <20%. What is our strategy?

Patients with left ventricular dysfunction and low ejection fraction (EF) are at high risk of complication and mortality after coronary artery bypass grafting (CABG). The potential success of off-pump CABG in this high-risk population has yet to be illustrated. Herein, we present our experience in regards to surgical planning and strategy on how to perform off-pump CABG in patients with very low EF.

Most deaths in low-risk cardiac surgery could be avoidable

It is observed that death rates in cardiac surgery has decreased, however, root causes that behave like triggers of potentially avoidable deaths (AD), especially in low-risk patients (less bias) are often unknown and underexplored, Phase of Care Mortality Analysis (POCMA) can be a valuable tool to identify seminal events (SE), providing valuable information where it is possible to make improvements in the quality and safety of future procedures. Our results show that in São Paul State, only one third of AD in low-risk cardiac surgery was related to specific surgical problems. After a revisited analysis, 75% of deaths could have been avoided, which in the pre-operative phase, the SE was related judgment, patient evaluation and preparation. In the intra-operative phase, most occurrences could have been avoided if other surgical technique had been used. Sepsis was responsible for 75% of AD in the intensive care unit. In the ward phase, the recognition/management of clinical decompensations and sepsis were the contributing factors. Logistic regression model identified age, previous coronary stent implantation, coronary artery bypass grafting + heart valve surgery, ≥ 2 combined heart valve surgery and hospital-acquired infection as independent predictors of AD.

A Comparison of Common Plastic Surgery Operations Using the NSQIP and TOPS Databases

Both the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) and the American Society of Plastic Surgeons Tracking Operations and Outcomes for Plastic Surgeons (TOPS) databases track 30-day outcomes.

Methods

Using the 2008-2016 TOPS and NSQIP databases, we compared patient characteristics and postoperative outcomes for 5 common plastic surgery procedures. A weighted TOPS population was used to mirror the NSQIP population in clinical and demographic characteristics to compare postoperative outcomes.

Results

We identified 154,181 cases. Compared with NSQIP patients, TOPS patients were more likely to be younger (47.9 versus 50.0 years), have American Society of Anesthesiologists class I-II (92.1% versus 74.6%), be outpatient (66.0% versus 49.3%), and be smokers (18.7% versus 11.7%). TOPS had extensive missing data: body mass index (40.6%), American Society of Anesthesiologists class (34.9%), diabetes (39.3%), and smoking status (37.2%). NSQIP was missing <1% of all shared categories except race (15.6%). The entire TOPS cohort versus only TOPS patients without missing data had higher rates of dehiscence (5.1% versus 3.5%) and infection (2.1% versus 1.7%). TOPS versus NSQIP patients had higher dehiscence rates (5.1% versus 1.0%) but lower rates of return to the operating room (3.1% versus 6.6%), infection (2.1% versus 3.0%), and medical complications (0.3% versus 2.2%). Nonweighted and weighted TOPS cohorts had similar 30-day outcomes.

Conclusions

NSQIP and TOPS populations are different in characteristics and outcomes, likely due to differences in collection methodology and the types physicians using the databases. The strengths of each dataset can be used together for research and quality improvement.

Advancing the Culture of Patient Safety and Quality Improvement

The American health care system has many great successes, but there continue to be opportunities for improving quality, access, and cost. The fee-for-service health care paradigm is shifting toward value-based care and will require accountability around quality assurance and cost reduction. As a result, many health care entities are rallying health care providers, administrators, regulators, and patients around a national imperative to create a culture of safety and develop systems of care to improve health care quality. However, the culture of patient safety and quality requires rigorous assessment of outcomes, and while numerous data collection and decision support tools are available to assist in quality assessment and performance improvement, the public reporting of this data can be confusing to patients and physicians alike and result in unintended negative consequences. This review explores the aims of health care reform, the national efforts to create a culture of quality and safety, the principles of quality improvement, and how these principles can be applied to patient care and medical practice.

Validation and quality measurements for STS, EuroSCORE II and a regional risk model in Brazilian patients

OBJECTIVES

The objectives of this study were to describe a novel statewide registry for cardiac surgery in Brazil (REPLICCAR), to compare a regional risk model (SPScore) with EuroSCORE II and STS, and to understand where quality improvement and safety initiatives can be implemented.

METHODS

A total of 11 sites in the state of São Paulo, Brazil, formed an online registry platform to capture information on risk factors and outcomes after cardiac surgery procedures for all consecutive patients. EuroSCORE II and STS values were calculated for each patient. An SPScore model was designed and compared with EuroSCORE II and STS to predict 30-day outcomes: death, reoperation, readmission, and any morbidity.

RESULTS

A total of 5222 patients were enrolled in this study between November 2013 and December 2017. The observed 30-day mortality rate was 7.6%. Most patients were older, overweight, and classified as New York Heart Association (NYHA) functional class III; 14.5% of the patient population had a positive diagnosis of rheumatic heart disease, 10.9% had insulin-dependent diabetes, and 19 individuals had a positive diagnosis of Chagas disease. When evaluating the prediction performance, we found that SPScore outperformed EuroSCORE II and STS in the prediction of mortality (0.90 vs. 0.76 and 0.77), reoperation (0.84 vs. 0.60 and 0.56), readmission (0.84 vs. 0.55 and 0.51), and any morbidity (0.80 vs. 0.65 and 0.64), respectively (p<0.001).

CONCLUSIONS

The REPLICCAR registry might stimulate the creation of other cardiac surgery registries in developing countries, ultimately improving the regional quality of care provided to patients.

Mortality Prediction After Cardiac Surgery: Higgins' Intensive Care Unit Admission Score Revisited

BACKGROUND

This study was performed to develop and validate a cardiac surgical intensive care risk adjustment model for mixed cardiac surgery based on a few preoperative laboratory tests, extracorporeal circulation time, and measurements at arrival to the intensive care unit.

METHODS

This was a retrospective study of admissions to 5 cardiac surgical intensive care units in Sweden that submitted data to the Swedish Intensive Care Registry. Admissions from 2008 to 2014 (n = 21,450) were used for model development, whereas admissions from 2015 to 2016 (n = 6463) were used for validation. Models were built using logistic regression with transformation of raw values or categorization into groups.

RESULTS

The final model showed good performance, with an area under the receiver operating characteristics curve of 0.86 (95% confidence interval, 0.83-0.89), a Cox calibration intercept of -0.16 (95% confidence interval, -0.47 to 0.19), and a slope of 1.01 (95% confidence interval, 0.89-1.13) in the validation cohort.

CONCLUSIONS

Eleven variables available on admission to the intensive care unit can be used to predict 30-day mortality after cardiac surgery. The model performance was better than those of general intensive care risk adjustment models used in cardiac surgical intensive care and also avoided the subjective assessment of the cause of admission. The standardized mortality ratio improves over time in Swedish cardiac surgical intensive care.

Systematic review and narrative synthesis of surgeons' perception of postoperative outcomes and risk

BACKGROUND

The accuracy with which surgeons can predict outcomes following surgery has not been explored in a systematic way. The aim of this review was to determine how accurately a surgeon's 'gut feeling' or perception of risk correlates with patient outcomes and available risk scoring systems.

METHODS

A systematic review was undertaken in accordance with PRISMA guidelines. A narrative synthesis was performed in accordance with the Guidance on the Conduct of Narrative Synthesis In Systematic Reviews. Studies comparing surgeons' preoperative or postoperative assessment of patient outcomes were included. Studies that made comparisons with risk scoring tools were also included. Outcomes evaluated were postoperative mortality, general and operation-specific morbidity and long-term outcomes.

RESULTS

Twenty-seven studies comprising 20 898 patients undergoing general, gastrointestinal, cardiothoracic, orthopaedic, vascular, urology, endocrine and neurosurgical operations were included. Surgeons consistently overpredicted mortality rates and were outperformed by existing risk scoring tools in six of seven studies comparing area under receiver operating characteristic (ROC) curves (AUC). Surgeons' prediction of general morbidity was good, and was equivalent to, or better than, pre-existing risk prediction models. Long-term outcomes were poorly predicted by surgeons, with AUC values ranging from 0·51 to 0·75. Four of five studies found postoperative risk estimates to be more accurate than those made before surgery.

CONCLUSION

Surgeons consistently overestimate mortality risk and are outperformed by pre-existing tools; prediction of longer-term outcomes is also poor. Surgeons should consider the use of risk prediction tools when available to inform clinical decision-making.

Performance Measures in Dermatologic Surgery: A Review of the Literature and Future Directions

BACKGROUND

In recent years, health care reform initiatives have aimed to assess quality of care through the use of performance measures. Multiple specialties, including dermatology, have implemented registries to track and report health care quality.

OBJECTIVE

The authors review the history and rationale for assessing quality in dermatologic surgery. The authors also discuss the different types of performance measures and the current efforts to develop clinically relevant dermatologic surgery-specific measures.

MATERIALS AND METHODS

An extensive literature review was conducted using OVID, MEDLINE, PubMed, and government and health care-related websites to identify articles related to surgical performance measures.

RESULTS

Few performance measures are established to assess quality in dermatologic surgery. The authors propose specific candidate measures and discuss how clinical registries can capture measures that meet federal reporting requirements.

CONCLUSION

Assessment of health care quality will become increasingly important in health care reform. Physicians need to take an active role in selecting appropriate, clinically relevant performance measures that will help improve patient care while containing health care costs and meeting government-mandated reporting requirements.

Feasibility of primary sternal plating for morbidly obese patients after cardiac surgery

Background

Morbidly obese patients (body mass index [BMI] ≥ 35 kg/m²) who undergo cardiac surgery involving median sternotomy have a higher-than-normal risk of sternal dehiscence. To explore a potential solution to this problem, we examined the utility of transverse sternal plating for primary sternal closure in morbidly obese cardiac surgical patients.

Methods

We retrospectively reviewed data from cardiac surgical patients who underwent single primary xiphoid transverse titanium plate reinforcement for primary sternal closure from August 2009 to July 2010 (n = 8), and we compared their outcomes with those of patients with BMI ≥35 kg/m² who underwent cardiac surgery without sternal plate reinforcement from April 2008 to July 2009 (n = 14). All cases were performed by the same surgeon.

Results

The 2 groups of patients had similar demographics and comorbidities (P > 0.05 for all). All patients with sternal plate reinforcement reported sternal stability at last follow-up (at a median of 27 months postoperatively; range, 8.4–49.3 months), whereas 1 patient (7.1%) who underwent standard closure developed sterile sternal dehiscence (P = 0.4). Postoperative patient-controlled analgesia (PCA) morphine usage was significantly higher for patients without sternal plate reinforcement than for patients who had sternal plate reinforcement (3.6 mg/h vs 1.3 mg/h, P = 0.008). No patient in the sternal plate group had wound seroma or perioperative complications attributable to sternal closure technique.

Conclusion

Single xiphoid transverse plate reinforcement for primary sternal closure is a feasible option for morbidly obese patients, who are otherwise at high risk of developing sternal dehiscence. Using this technique may decrease postoperative narcotics usage.

Ultramini abstract

Morbidly obese patients (body mass index ≥35 kg/m²) have a higher-than-normal risk of sternal dehiscence after cardiac surgery. In a pilot study, we found that those who underwent transverse sternal plating (n = 8) had no sternal dehiscence and required less postoperative analgesia than patients who underwent standard wire closure (n = 14).

Mapping standard ophthalmic outcome sets to metrics currently reported in eight eye hospitals

Background

To determine alignment of proposed international standard outcomes sets for ophthalmic conditions to metrics currently reported by eye hospitals.

Methods

Mixed methods comparative benchmark study, including eight eye hospitals in Australia, India, Singapore, Sweden, U.K., and U.S. All are major international tertiary care and training centers in ophthalmology. Main outcome measure is consistency of ophthalmic outcomes measures reported.

Results

International agreed standard outcomes (ICHOM) sets are available for cataract surgery (10 metrics) and macular degeneration (7 metrics). The eight hospitals reported 22 different metrics for cataract surgery and 2 for macular degeneration, which showed only limited overlap with the proposed ICHOM metrics. None of the hospitals reported patient reported visual functioning or vision-related quality of life outcomes measures (PROMs). Three hospitals (38%) reported rates for uncomplicated cataract surgeries only. There was marked variation in how and at what point postoperatively visual outcomes following cataract, cornea, glaucoma, strabismus and oculoplastics procedures were reported. Seven (87.5%) measured post-operative infections and four (50%) measured 30 day unplanned reoperation rates.

Conclusions

Outcomes reporting for ophthalmic conditions currently widely varies across hospitals internationally and does not include patient-reported outcomes. Reaching consensus on measures and consistency in data collection will allow meaningful comparisons and provide an evidence base enabling improved sharing of “best practices” to improve eye care globally. Implementation of international standards is still a major challenge and practice-based knowledge on measures should be one of the inputs of the international standardization process.

Electronic supplementary material

The online version of this article (doi: 10.1186/s12886-017-0667-0) contains supplementary material, which is available to authorized users.

Five-Year Outcomes after On-Pump and Off-Pump Coronary-Artery Bypass

BACKGROUND

Coronary-artery bypass grafting (CABG) surgery may be performed either with cardiopulmonary bypass (on pump) or without cardiopulmonary bypass (off pump). We report the 5-year clinical outcomes in patients who had been included in the Veterans Affairs trial of on-pump versus off-pump CABG.

METHODS

From February 2002 through June 2007, we randomly assigned 2203 patients at 18 medical centers to undergo either on-pump or off-pump CABG, with 1-year assessments completed by May 2008. The two primary 5-year outcomes were death from any cause and a composite outcome of major adverse cardiovascular events, defined as death from any cause, repeat revascularization (CABG or percutaneous coronary intervention), or nonfatal myocardial infarction. Secondary 5-year outcomes included death from cardiac causes, repeat revascularization, and nonfatal myocardial infarction. Primary outcomes were assessed at a P value of 0.05 or less, and secondary outcomes at a P value of 0.01 or less.

RESULTS

The rate of death at 5 years was 15.2% in the off-pump group versus 11.9% in the on-pump group (relative risk, 1.28; 95% confidence interval [CI], 1.03 to 1.58; P=0.02). The rate of major adverse cardiovascular events at 5 years was 31.0% in the off-pump group versus 27.1% in the on-pump group (relative risk, 1.14; 95% CI, 1.00 to 1.30; P=0.046). For the 5-year secondary outcomes, no significant differences were observed: for nonfatal myocardial infarction, the rate was 12.1% in the off-pump group and 9.6% in the on-pump group (P=0.05); for death from cardiac causes, the rate was 6.3% and 5.3%, respectively (P=0.29); for repeat revascularization, the rate was 13.1% and 11.9%, respectively (P=0.39); and for repeat CABG, the rate was 1.4% and 0.5%, respectively (P=0.02).

CONCLUSIONS

In this randomized trial, off-pump CABG led to lower rates of 5-year survival and event-free survival than on-pump CABG. (Funded by the Department of Veterans Affairs Office of Research and Development Cooperative Studies Program and others; ROOBY-FS ClinicalTrials.gov number, NCT01924442 .).

Big data in facial plastic and reconstructive surgery: from large databases to registries

PURPOSE OF REVIEW

There are many limitations to performing clinical research with high levels of evidence in facial plastic and reconstructive surgery (FPRS), such as randomization into surgical groups and sample size recruitment. Therefore, additional avenues for exploring research should be explored using big data, from databases to registries. Other organizations have developed these tools in the evolving landscape of outcomes measurement and value in healthcare, which may serve as models for our specialty.

RECENT FINDINGS

Over the last 5 years, FPRS literature of large-scale outcomes research, utilizing several administrative databases, has steadily grown. Our objectives are to describe key administrative databases, strengths and weaknesses of each, and identify recent FPRS publications utilizing big data. A registry with FPRS defined outcomes has the most potential.

SUMMARY

Although FPRS research has trended to a more evidence-based approach in the modern healthcare era, gaps persist. Several large administrative databases or registries can address voids in outcomes research within FPRS.

Effect of coronary artery bypass graft surgery on left ventricular systolic function

BACKGROUND

Changes in left ventricular (LV) systolic function in response to coronary artery bypass grafting (CABG) have not been fully assessed.

METHODS

Between January 2001 and December 2014, 2,838 consecutive patients underwent isolated CABG at the Minneapolis Veterans Affairs Health Care System. Of these, 375 had echocardiographic assessment of LV function before (within 6 months) and after (3 to 24 months) CABG and were included in this analysis.

RESULTS

While the mean LV ejection fraction (LVEF) did not change following CABG [(49±13)% vs. (49±12)%, P=0.51], LVEF decreased in the subgroup with normal (≥50%) pre-operative LVEF [from (59±5)% to (56±9)%, P<0.001] and improved in those with decreased (<50%) pre-operative LVEF [from (36±9)% to (41±12)%, P<0.001]. There was a significant reduction in LV internal diameter during end-diastole (LVIDd) (5.4±0.8 vs. 5.3±0.9, P=0.002) and an increase in left atrial diameter (LAD) (4.4±0.7 vs. 4.6±0.7, P<0.001). There were no perioperative changes in LV internal diameter during end-systole, LV mass, posterior wall thickness, or septal wall thickness. LVEF improved by >5% in 24% of the study population, did not change (+/- 5%) in 55%, and worsened by >5% in 21%. Patients with improved EF were less often diabetic and had lower pre-operative LVEF, and greater LV dimensions at baseline.

CONCLUSIONS

After CABG, there was a decrease in LVIDd and an increase in LAD. Also, a decrease in LV systolic function with CABG was observed in patients with normal pre-operative LVEF and an improvement in LV systolic function was observed in patients with decreased pre-operative LVEF.

Significant regional variation exists in morbidity and mortality after repair of abdominal aortic aneurysm

OBJECTIVE

Limited data exist comparing perioperative morbidity and mortality after open and endovascular abdominal aortic aneurysm (AAA) repair (EVAR) among regions of the United States. This study evaluated the regional variation in mortality and perioperative outcomes after repair of AAAs.

METHODS

The Vascular Quality Initiative (VQI) was used to identify patients undergoing open AAA repair and EVAR between 2009 and 2014. Ruptured and intact aneurysms were evaluated separately, and the analysis of intact aneurysms was limited to infrarenal AAAs. All 16 regions of the VQI were deidentified, and those with <100 open repairs were combined to eliminate the effect of low-volume regions. Regional variation was evaluated using χ² and Fisher exact tests. Regional rates were compared against current quality benchmarks.

RESULTS

Perioperative outcomes from 14 regions were compared. After open repair of intact aneurysms, no significant variation was seen in 30-day or in-hospital mortality; however, multiple regions exceeded the Society for Vascular Surgery benchmark for in-hospital mortality after open repair of intact aneurysms of <5% (range, 0%-7%; P = .55). After EVAR, all regions met the Society for Vascular Surgery benchmark of <3% (range, 0%-1%; P = .75). Significant variation in in-hospital mortality existed after open (14%-63%; P = .03) and endovascular (3%-32%; P = .03) repair of ruptured aneurysms across the VQI regional groups. After repair of intact aneurysms, wide variation was seen in prolonged length of stay (>7 days for open repair: 32%-53%, P = .54; >2 days for EVAR: 16-43%, P < .01), transfusion (open: 10%-35%, P < .01; EVAR: 7%-18%, P < .01), use of vasopressors (open: 19%-37%, P < .01; EVAR: 3%-7%, P < .01), and postoperative myocardial infarction (open: 0%-13%, P < .01; EVAR: 0%-3%, P < .01). After open repair, worsening renal function (6%-18%; P = .04) and respiratory complications (6%-20%; P = .20) were variable across regions. The frequency of endoleak at completion of EVAR also had considerable variation (15%-38%; P < .01).

CONCLUSIONS

Despite limited variation, multiple regions do not meet current benchmarks for in-hospital mortality after open AAA repair for intact aneurysms. Significant regional variation exists in perioperative outcomes and length of stay, and mortality is widely variable after repair for rupture. These data identify important areas for quality improvement initiatives and clinical practice guidelines.

Improving Indicators in a Brazilian Hospital Through Quality-Improvement Programs Based on STS Database Reports

OBJECTIVE

To report the initial changes after quality-improvement programs based on STS-database in a Brazilian hospital.

METHODS

Since 2011 a Brazilian hospital has joined STS-Database and in 2012 multifaceted actions based on STS reports were implemented aiming reductions in the time of mechanical ventilation and in the intensive care stay and also improvements in evidence-based perioperative therapies among patients who underwent coronary artery bypass graft surgeries.

RESULTS

All the 947 patients submitted to coronary artery bypass graft surgeries from July 2011 to June 2014 were analyzed and there was an improvement in all the three target endpoints after the implementation of the quality-improvement program but the reduction in time on mechanical ventilation was not statistically significant after adjusting for prognostic characteristics.

CONCLUSION

The initial experience with STS registry in a Brazilian hospital was associated with improvement in most of targeted quality-indicators.

Incidence, Predictors, and Impact of Postoperative Atrial Fibrillation after Coronary Artery Bypass Grafting in Military Veterans

Little is known about the frequency and clinical implications of postoperative atrial fibrillation in military veterans who undergo coronary artery bypass grafting (CABG). We examined long-term survival data, clinical outcomes, and associated risk factors in this population. We retrospectively reviewed baseline, intraoperative, and postoperative data from 1,248 consecutive patients with similar baseline risk profiles who underwent primary isolated CABG at a Veterans Affairs hospital from October 2006 through March 2013. Multivariable logistic regression identified predictors of postoperative atrial fibrillation. Kaplan-Meier analysis was used to evaluate long-term survival (the primary outcome measure), morbidity, and length of hospital stay. Postoperative atrial fibrillation occurred in 215 patients (17.2%). Independent predictors of this sequela were age ≥65 years (odds ratios [95% confidence intervals], 1.7 [1.3-2.4] for patients of age 65-75 yr and 2.6 [1.4-4.8] for patients >75 yr) and body mass index ≥30 kg/m² (2.0 [1.2-3.2]). Length of stay was longer for patients with postoperative atrial fibrillation than for those without (12.7 ± 6.6 vs 10.3 ± 8.9 d; P ≤0.0001), and the respective 30-day mortality rate was higher (1.9% vs 0.4%; P=0.014). Seven-year survival rates did not differ significantly. Older and obese patients are particularly at risk of postoperative atrial fibrillation after CABG. Patients who develop the sequela have longer hospital stays than, but similar long-term survival rates to, patients who do not.

Early outcomes of on-pump versus off-pump coronary artery bypass grafting

Objectives:

To see the early post-operative outcomes of off-pump versus on-pump coronary artery bypass graft surgery.

Methods:

This retrospective analytical study was conducted at Ch. Pervaiz Elahi Institute of Cardiology Multan, Pakistan. Our Primary outcome variables were; necessity of inotropic support, nonfatal myocardial infarction, ICU stay, nonfatal stroke, new renal failure requiring dialysis and death within 30 days after operation. There were two groups of patients; Group-I (On-pump group) and Group-II (Off-pump Group). SPSS V17 was used for data analysis. Independent sample t-test and Mann Whitney U test were used to compare quantitative Variables. Chi-square test and Fisher’s exact test were used to analyze qualitative variables. P-value ≤ 0.05 was considered significant.

Results:

Three hundred patients were included in this study. There were no significant difference regarding risk factors except hyper-cholestrolemia which was high in off pump group (p-value 0.05). Angiographic and Echocardiographic characteristics e.g. preoperative ejection fraction, LV function grade and severity of CAD was same between the groups. Mortality risk scores and Priority status for surgery were also same. Regarding post-operative outcomes; Post-op CKMB Levels, need and duration of inotropic support, mechanical ventilation time and ICU stay was significantly less in Off-Pump group (p-value 0.001, <0.0001, 0.006, 0.025 and 0.001 resp.). Peri-operative chest drainage was significantly high in On-pump CABG group (p-value 0.027). Incidence of post-op complications was not statistically different between the groups.

Conclusions:

At 30 days follow-up, Incidence of myocardial infarction, necessity and duration of inotropic support, ICU stay period and peri-operative bleeding were significantly less in off-pump group. The incidence of neurologic, pulmonary and renal complications was same between the off-pump and on-pump groups.

Phase of Care Mortality Analysis: A Unique Method for Comparing Mortality Differences Among Transcatheter Aortic Valve Replacement and Surgical Aortic Valve Replacement Patients

The objective of this study is based on the phase of care mortality analysis (POCMA), an effective tool to evaluate the root cause of in-hospital mortality in cardiac surgery patients. POCMA has not been used to compare operative mortalities among transcatheter aortic valve replacement (TAVR) and surgical aortic valve replacement (SAVR) populations, and may provide insight that could affect patient safety initiatives and improve outcomes in aortic valve surgery. We included patients who underwent TAVR or isolated SAVR between 2011 and March 31, 2015 and did not survive the index hospitalization. A multidisciplinary heart team made POCMA assignments as part of the weekly morbidity and mortality conference, pinpointing the phase of care and subcategory that directly caused or had the greatest effect on each mortality. During the study period, 240 patients underwent TAVR and 530 underwent SAVR. Unadjusted mortality rates were significantly higher in the TAVR group, 5.0% (n = 12) compared with SAVR, 1.9% (n = 10) (P = 0.016). TAVR deaths by phase of care are as follows: 0 for preoperative, 9 (72.8%) for intraoperative, 2 (18.2%) for postoperative intensive care unit, and 1 (9.1%) for postoperative floor. By comparison, 4 (40%) SAVR deaths had a root cause in the preoperative phase, 1 (10%) in the intraoperative phase, and 5 (50%) in the postoperative intensive care unit phase. POCMA is a novel method of categorizing in-hospital mortalities. Our single institution review revealed that patients who underwent TAVR more often expired because of intraoperative technical issues, whereas SAVR deaths were typically the result of patient selection or postoperative complications.

Should Risk Adjustment for Surgical Outcomes Reporting Include Sociodemographic Status? A Study of Coronary Artery Bypass Grafting in California

BACKGROUND

Public reporting of surgical outcomes must adjust for patient risk. However, whether patient sociodemographic status (SDS) should be included is debatable. Our objective was to empirically compare risk-adjustment models and hospital ratings with or without SDS factors for patients undergoing coronary artery bypass grafting.

STUDY DESIGN

This is a retrospective analysis of the California Coronary Artery Bypass Grafting Outcomes Reporting Program, 2011-2012. Outcomes included 30-day or in-hospital mortality, perioperative stroke, and 30-day readmission. Sociodemographic status factors included race, language, insurance, ZIP code-based median income, and percent that were a college graduate. The c-statistic and goodness-of-fit were compared between models with and without SDS factors. Differences in hospital performance rating when adjusting for SDS were also compared.

RESULTS

None of the SDS factors predicted mortality. Income, education, and language had no impact on any outcomes. Insurance predicted stroke (MediCal vs private insurance, odds ratio [OR] = 1.91; 95% CI, 1.11-3.31; p = 0.020) and readmissions (Medicare vs private insurance, OR = 1.36; 95% CI, 1.16-1.61; p < 0.001; MediCal vs private insurance, OR = 1.56; 95% CI, 1.26-1.94; p < 0.001). Race also predicted stroke (Asian vs white, OR = 2.26; p < 0.001). Adding SDS factors improved the c-statistic in readmission only (0.652 vs 0.645; p = 0.008). Goodness-of-fit worsened when adding SDS factors to mortality models, but was no different in stroke or readmissions. Hospital performance rating only changed in readmissions; of 124 hospitals, only 1 hospital moved from "better" to "average" when adjusting for SDS.

CONCLUSIONS

Adjusting for insurance improves statistical models when analyzing readmissions after coronary artery bypass grafting, but does not impact hospital performance ratings substantially. Deciding whether SDS should be included in a patient's risk profile depends on valid measurements of SDS and requires a nuanced approach to assessing how these variables improve risk-adjusted models.

Regional variation exists in patient selection and treatment of abdominal aortic aneurysms

OBJECTIVE

Significant regional variation in surgical rates has been identified following multiple surgical procedures. However, limited data have examined the regional variability in patient selection and treatment of abdominal aortic aneurysms (AAAs). This study aimed to evaluate regional variation in patient selection, perioperative management, and operative approach for the repair of AAAs.

METHODS

All patients undergoing open repair or endovascular aneurysm repair (EVAR) of an AAA in the Vascular Quality Initiative from 2009 to 2014 were identified. All regional groups were deidentified, and those with fewer than 100 open repairs were combined into a single region.

RESULTS

We identified 17,269 elective repairs (EVAR, 13,759; open, 3510) and 1462 ruptured AAAs (EVAR, 749; open, 713). There was significant regional variation in the use of EVAR for elective repair (range, 66%-88%; P < .01) and ruptured AAA repair (40%-80%; P < .01). The median diameter for elective repair was similar among regions (EVAR, 5.4 cm; open, 5.7 cm). There was wide variation in the treatment of small aneurysms in male patients (<5.5 cm) for EVAR (34%-49%; P < .01) and open repair (17%-38%; P < .01) and variation in the treatment of small aneurysms in female patients (<5 cm) for EVAR (14%-32%; P < .01) but not significant for open repair (6%-24%). For elective cases, preoperative aspirin (EVAR, 50%-75% [P < .01]; open, 49%-78% [P < .01]) and statin use (EVAR, 61%-75% [P < .01]; open, 56%-80% [P < .01]) varied widely. Among elective cardiac patients, preoperative management varied significantly, including beta-blocker use (EVAR, 66%-78% [P < .01]; open, 69%-88% [P = .01]) and the frequency of stress tests (EVAR, 33%-64% [P < .01]; open, 31%-73% [P < .01]). Among open repairs for aneurysms extending at or beyond the juxtarenal segment, there was wide variation in the use of retroperitoneal exposures (7%-70%; P < .01) and adjunctive renal protective measures (cold renal perfusion, 2%-43% [P < .01]; mannitol, 47%-92% [P < .01]).

CONCLUSIONS

Significant regional variation exists in patient selection, perioperative management, and operative approach for the repair of AAA. Definitive evidence is lacking in many aspects of operative care, including the use of the retroperitoneal approach and renal protective strategies. However, this variation emphasizes the importance of research to determine best practice in the areas of greatest variation. Furthermore, where current clinical process measures exist and data are clear, such as the use of statin and antiplatelet agents, the high degree of variation should serve as an impetus for regional quality improvement projects.

Development of the Cardiac Surgery Patient Expectations Questionnaire (C-SPEQ)

PURPOSE

Some variability in recovery and outcomes after cardiac surgery may be influenced by psychosocial aspects not routinely captured. Preliminary evidence suggests patient expectations impact health status, but there is no specific measure of expectations for cardiac surgery. The purpose of this study was to adapt an expectations scale to cardiac surgery and assess the psychometric properties of the scale.

METHODS

Before surgery, 93 patients awaiting non-emergent cardiac surgery completed questionnaires, including the adapted Cardiac Surgery Patient Expectations Questionnaire (C-SPEQ). At 1 year after surgery, 68 patients completed questionnaires.

RESULTS

Mean C-SPEQ score was 39.4 ± 9.02, and scores were normally distributed (Cronbach's alpha = 0.86). Higher score indicated negative expectations. Higher presurgery C-SPEQ score was correlated with greater depression (r = 0.32, p = 0.01) and perceived stress (r = 0.36, p = 0.003), but not state anxiety (r = 0.18, p = 0.14), at one-year post-surgery. Higher C-SPEQ was associated with longer recovery time (B = 0.14, p = 0.006) and lower physical HRQL after surgery (B = -0.31, p = 0.005). Higher C-SPEQ was not related to greater odds for perioperative complications (OR 1.01, p = 0.68) or readmissions <30 days (OR 1.05, p = 0.31). C-SPEQ score was not related to survival.

CONCLUSIONS

Adaptation of an expectations questionnaire to cardiac surgery patients was successful with acceptable reliability and validity. Negative expectations had a detrimental impact on recovery and HRQL following cardiac surgery but were not related to clinical outcomes. Although focus is mainly on improving clinical outcomes, there are opportunities to improve non-clinical aspects of the patient experience. Presurgical education might better prepare patients, reduce negative expectations, and improve psychosocial outcomes after cardiac surgery.

The Chinese Cardiac Surgery Registry: Design and Data Audit

BACKGROUND

In light of the burgeoning volume and certain variation of in-hospital outcomes of cardiac operations in China, a large patient-level registry was needed. We generated the Chinese Cardiac Surgery Registry (CCSR) database in 2013 to benchmark, continuously monitor, and provide feedback of the quality of adult cardiac operations. We report on the design of this database and provide an overview of participating sites and quality of data.

METHODS

We established a network of participating sites with an adult cardiac surgery volume of more than 100 operations per year for continuous web-based registry of in-hospital and follow-up data of coronary artery bypass grafting (CABG) and valve operations. After a routine data quality audit, we report the performance and quality of care back to the participating sites.

RESULTS

In total, 87 centers participated and submitted 46,303 surgical procedures from January 2013 to December 2014. The timeliness rates of the short-list and in-hospital data submitted were 73.6% and 70.2%, respectively. The completeness and accuracy rates of the in-hospital data were 97.6% and 95.1%, respectively. We have provided 2 reports for each site and 1 national report regarding the performance of isolated CABG and valve operations.

CONCLUSIONS

The newly launched CCSR with a national representativeness network and good data quality has the potential to act as an important platform for monitoring and improving cardiac surgical care in mainland China, as well as facilitating research projects, establishing benchmarking standards, and identifying potential areas for quality improvements (ClinicalTrials.gov No. NCT02400125).

Identifying and defining complications of dermatologic surgery to be tracked in the American College of Mohs Surgery (ACMS) Registry

BACKGROUND

In recent years, increasing emphasis has been placed on value-based health care delivery. Dermatology must develop performance measures to judge the quality of services provided. The implementation of a national complication registry is one such method of tracking surgical outcomes and monitoring the safety of the specialty.

OBJECTIVE

The purpose of this study was to define critical outcome measures to be included in the complications registry of the American College of Mohs Surgery (ACMS).

METHODS

A Delphi process was used to reach consensus on the complications to be recorded.

RESULTS

Four major and one minor complications were selected: death, bleeding requiring additional intervention, functional loss attributable to surgery, hospitalization for an operative complication, and surgical site infection.

LIMITATIONS

This article addresses only one aspect of registry development: identifying and defining surgical complications.

CONCLUSION

The ACMS Registry aims to gather data to monitor the safety and value of dermatologic surgery. Determining and defining the outcomes to be included in the registry is an important foundation toward this endeavor.

The Society of Thoracic Surgeons Adult Cardiac Surgery Database: The Driving Force for Improvement in Cardiac Surgery

Initiated in 1989, the Society of Thoracic Surgeons (STS) Adult Cardiac Surgery Database (ACSD) includes more than 1085 participating centers, representing 90%-95% of current US-based adult cardiac surgery hospitals. Since its inception, the primary goal of the STS ACSD has been to use clinical data to track and improve cardiac surgical outcomes. Patients' preoperative risk characteristics, procedure-related processes of care, and clinical outcomes data have been captured and analyzed, with timely risk-adjusted feedback reports to participating providers. In 2006, STS initiated an external audit process to evaluate STS ACSD completeness and accuracy. Given the extremely high inter-rater reliability and completeness rates of STS ACSD, it is widely regarded as the "gold standard" for benchmarking cardiac surgery risk-adjusted outcomes. Over time, STS ACSD has expanded its quality horizons beyond the traditional focus on isolated, risk-adjusted short-term outcomes such as perioperative morbidity and mortality. New quality indicators have evolved including composite measures of key processes of care and outcomes (risk-adjusted morbidity and risk-adjusted mortality), longer-term outcomes, and readmissions. Resource use and patient-reported outcomes would be added in the future. These additional metrics provide a more comprehensive perspective on quality as well as additional end points. Widespread acceptance and use of STS ACSD has led to a cultural transformation within cardiac surgery by providing nationally benchmarked data for internal quality assessment, aiding data-driven quality improvement activities, serving as the basis for a voluntary public reporting program, advancing cardiac surgery care through STS ACSD-based research, and facilitating data-driven informed consent dialogues and alternative treatment-related discussions.

Clinical registries and quality measurement in surgery: a systematic review

BACKGROUND

Surgical clinical registries provide clinical information with the intent of measuring and improving quality. This study aimed to describe how surgical clinical registries have been used to measure surgical quality, the reported findings, and the limitations of registry measurements.

METHODS

Medline, CINAHL, and Cochrane were queried for English articles with the terms: "registry AND surgery AND quality." Eligibility criteria were studies explicitly assessing quality measurement with registries as the primary data source. Studies were abstracted to identify registries, define registry structure, uses for quality measurement, and limitations of the measurements used.

RESULTS

A total of 111 studies of 18 registries were identified for data abstraction. Two registries were financed privately, and 5 registries were financed by a governmental organization. Across registries, the most common uses of process measures were for monitoring providers and as platforms for quality improvement initiatives. The most common uses of outcome measures were to improve quality modeling and to identify preoperative risk factors for poor outcomes. Eight studies noted improvements in risk-adjusted mortality with registry participation; one found no change. A major limitation is bias from context and means of data collection threatening internal validity of registry quality measurement. Conversely, the other major limitation is the cost of participation, which threatens the external validity of registry quality measurement.

CONCLUSION

Clinical registries have advanced surgical quality definition, measurement, and modeling as well as having served as platforms for local initiatives for quality improvement. The implication of this finding is that subsidizing registry participation may improve data validity as well as engage providers in quality improvement.

Association of hospital-level volume of extracorporeal membrane oxygenation cases and mortality. Analysis of the extracorporeal life support organization registry

RATIONALE

Recent pediatric studies suggest a survival benefit exists for higher-volume extracorporeal membrane oxygenation (ECMO) centers.

OBJECTIVES

To determine if higher annual ECMO patient volume is associated with lower case-mix-adjusted hospital mortality rate.

METHODS

We retrospectively analyzed an international registry of ECMO support from 1989 to 2013. Patients were separated into three age groups: neonatal (0-28 d), pediatric (29 d to <18 yr), and adult (≥18 yr). The measure of hospital ECMO volume was age group-specific and adjusted for patient-level case-mix and hospital-level variance using multivariable hierarchical logistic regression modeling. The primary outcome was death before hospital discharge. A subgroup analysis was conducted for 2008-2013.

MEASUREMENTS AND MAIN RESULTS

From 1989 to 2013, a total of 290 centers provided ECMO support to 56,222 patients (30,909 neonates, 14,725 children, and 10,588 adults). Annual ECMO mortality rates varied widely across ECMO centers: the interquartile range was 18-50% for neonates, 25-66% for pediatrics, and 33-92% for adults. For 1989-2013, higher age group-specific ECMO volume was associated with lower odds of ECMO mortality for neonates and adults but not for pediatric cases. In 2008-2013, the volume-outcome association remained statistically significant only among adults. Patients receiving ECMO at hospitals with more than 30 adult annual ECMO cases had significantly lower odds of mortality (adjusted odds ratio, 0.61; 95% confidence interval, 0.46-0.80) compared with adults receiving ECMO at hospitals with less than six annual cases.

CONCLUSIONS

In this international, case-mix-adjusted analysis, higher annual hospital ECMO volume was associated with lower mortality in 1989-2013 for neonates and adults; the association among adults persisted in 2008-2013.

Preventive use of intra-aortic balloon pump in patients undergoing high-risk coronary artery bypass grafting: a retrospective study

Background

Coronary artery bypass grafting (CABG) is an important therapeutic measure for CHD patients. The patients who score more than 12 EuroSCORE points cannot achieve good results because of their low cardiac output and delicate left ventricular function. Therefore, use of an intra-aortic balloon pump (IABP) is essential for coronary surgical patients in the peri-operative period. At present, there is no unified standard about when to insert an IABP. This study aimed to compare the short-term clinical outcomes of the IABP inserted in the preoperative condition with its use in the emergency condition for extremely high-risk patients.

Material/Methods

IABP support time, respirator support time, and ICU stay time were significantly shorter (all p<0.05) in the preoperative IABP group compared to the emergency IABP group, and the rates of low cardiac output syndrome (LCOS), acute myocardial infarction, and acute kidney injury in the preoperative group were also significantly lower in the preoperative IABP group (all p<0.05). There were no significant differences in IABP-related complications and the mortality (p=0.106) between two groups.

Results

Compared to the emergency IABP group, the IABP support time, respirator support time and ICU stay time were significantly lower in the preoperative IABP group (all p<0.05), and the rates of LCOS, acute myocardial infarction, and acute kidney injury in the preoperative group were also significantly lower (all p<0.05). There were no significant differences in IABP-related complications and the mortality (p=0.106) between the 2 groups.

Conclusions

For high-risk patients with CABG, preoperative IABP insertion is a safe and effective measure.

Evaluation of the Society of Thoracic Surgeons score system for isolated coronary bypass graft surgery in a Brazilian population

Objective

Report the experience with the Society of Thoracic Surgeons scoring system in a Brazilian population submitted to isolated coronary artery bypass graft surgery.

Methods

Data were collected from January-2010 to December-2011, and analyzed to determine the performance of the Society of Thoracic Surgeons scoring system on the determination of postoperative mortality and morbidity, using the method of the receiver operating characteristic curve as well as the Hosmer-Lemeshow and the Chi-square goodness of fit tests. From the 1083 cardiac surgeries performed during the study period 659 represented coronary artery bypass graft procedures which are included in the present analysis. Mean age was 61.4 years and 77% were men.

Results

Goodness of fit tests have shown good calibration indexes both for mortality (X²=6.78, P=0.56) and general morbidity (X²=6.69, P=0.57). Analysis of area under the ROC-curve (AUC) demonstrated a good performance to detect the risk of death (AUC 0.76; P<0.001), renal failure (AUC 0.79; P<0.001), prolonged ventilation (AUC 0.80; P<0.001), reoperation (AUC 0.76; P<0.001) and major morbidity (AUC 0.75; P<0.001) which represents the combination of the assessed postoperative complications. STS scoring system did not present comparable results for short term hospital stay, prolonged length of hospital stay and could not be properly tested for stroke and wound infection.

Conclusion

Society of Thoracic Surgeons scoring system presented a good calibration and discrimination in our population to predict postoperative mortality and the majority of the harmful events following coronary artery bypass graft surgery. Analysis of larger samples might be needed to further validate the use of the score system in Brazilian populations.

The national clinical database as an initiative for quality improvement in Japan

The JCVSD (Japan Cardiovascular Surgery Database) was organized in 2000 to improve the quality of cardiovascular surgery in Japan. Web-based data harvesting on adult cardiac surgery was started (Japan Adult Cardiovascular Surgery Database, JACVSD) in 2001, and on congenital heart surgery (Japan Congenital Cardiovascular Surgery Database, JCCVSD) in 2008. Both databases grew to become national databases by the end of 2013. This was influenced by the success of the Society for Thoracic Surgeons' National Database, which contains comparable input items. In 2011, the Japanese Board of Cardiovascular Surgery announced that the JACVSD and JCCVSD data are to be used for board certification, which improved the quality of the first paperless and web-based board certification review undertaken in 2013. These changes led to a further step. In 2011, the National Clinical Database (NCD) was organized to investigate the feasibility of clinical databases in other medical fields, especially surgery. In the NCD, the board certification system of the Japan Surgical Society, the basic association of surgery was set as the first level in the hierarchy of specialties, and nine associations and six board certification systems were set at the second level as subspecialties. The NCD grew rapidly, and now covers 95% of total surgical procedures. The participating associations will release or have released risk models, and studies that use 'big data' from these databases have been published. The national databases have contributed to evidence-based medicine, to the accountability of medical professionals, and to quality assessment and quality improvement of surgery in Japan.